Medical Claims Appeals Manager

Valenz® Health simplifies the complexities of self-insurance for employers through a steadfast commitment to data transparency and decision enablement powered by its Healthcare Ecosystem Optimization Platform. Offering a strong foundation with deep roots in clinical and member advocacy, alongside decades of expertise in claim reimbursement and payment validity, integrity, and accuracy, as well as a suite of risk affinity solutions, Valenz optimizes healthcare for the provider, payer, plan, and member. By establishing “true transparency” and offering data-driven solutions that improve cost, quality, and outcomes for employers and their members, Valenz engages early and often for smarter, better, faster healthcare.

About Our Opportunity

As a Medical Claims Appeals Manager, you will play a pivotal role in overseeing the highest level of appeals within the organization. You will lead a team of professionals and be the primary escalation point for complex cases.

Things You’ll Do Here:

• Lead a team of appeals specialists, providing guidance and supervision to ensure efficient and effective handling of appeals.
• Serve as the final escalation point for complex and high-level appeals, bringing your expertise to cases that require a senior level of analysis.
• Receive, review, and address appeals from providers, ensuring that all appeals are processed in accordance with ERISA, plan guidelines, and other applicable regulations.
• Maintain strict compliance with company policies, procedures, and relevant regulations.
• Conduct audits and reviews to maintain the highest standards of quality in the appeals process.
• Generate reports and analyze key performance indicators (KPIs) to identify trends and areas for improvement.
• Provide insights and recommendations to enhance overall efficiency and effectiveness.
• Review and approve negotiation thresholds, assessing the terms and conditions of settlements proposed during the appeals process.
• Collaborate with cross-functional teams to contribute to the development of strategic initiatives related to appeals management.
• Work closely with legal, compliance, and other key stakeholders to ensure appeals processes align with regulatory requirements and internal policies.

Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

Where You’ll Work

This is a remote role.

Why You Will Love Working Here

We offer employee perks that go beyond standard benefits and compensation packages – see below!

At Valenz, our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. We want everyone engaged within our ecosystem to be strong, vigorous, and healthy. You’ll find limitless growth opportunities as we grow together. If you're ready to utilize your skills and passion to make a significant impact in the healthcare self-funded space, Valenz might be the perfect place for you!

Perks and Benefits

• Generously subsidized company-sponsored Medical, Dental, and Vision insurance.
• Spending account options: HSA, FSA, and DCFSA
• 401K with company match and immediate vesting.
• Flexible working environment.
• Generous Paid Time Off to include Vacation, Sick, and Paid Holidays.
• Paid maternity and paternity leave.
• Community giveback opportunities, including paid time off for philanthropic endeavors.

At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products.?Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.

What You’ll Bring to the Team:

• 5+ years of experience in analyzing, denying, or settling out-of-network appeals.
• 2+ years in a management role (supervisor or team lead experience will be considered).
• Proficient in CPT-4, HCPCS, Revenue, DRG, and ICD-10 coding for precise claim reviews.
• Familiarity with the No Surprise Act, ERISA guidelines, and relevant legislations.
• Demonstrated negotiation skills with providers for claim adjustments and counteroffers.
• Strong analytical ability for evaluating claims using pricing tools and historical data.

A plus if you have…

• Bachelor’s Degree
• Experience with international plans
• Experience in self-funded insurance